What is the optimal chemotherapy regimen for overall quality of life for patients in the treatment of stage IV inoperable NSCLC?

Introduction

The majority of patients treated with NSCLC have stage IV disease, with common sites of metastases including lymph nodes, the pleura, liver, adrenal glands, bone and brain. Consequently, systemic therapy has been the mainstay of treatment attempting to control overall disease. A historical summary of the evolution of systemic drug treatment for stage IV NSCLC can be found here.
The focus of the following question is based on the evidence in support of the old and new practice paradigms for stage IV NSCLC. Empirical therapy refers to therapy given to all fit patients deemed suitable without any particular restrictions.

Different chemotherapy regimens and health related quality of life

Many of the aforementioned clinical trials have formally included patient rated QOL evaluation usually as a secondary endpoint. The overall effect of common chemotherapy regimens on health related QOL in NSCLC is probably best summarised in the meta-analysis by Tanvetyanon et al.[1] This study identified 14 RCTs from 1998 – 2005 with 6665 patients to determine differences in QOL between the regimens studies. Of these, 13 trials using a validated QOL instrument were included for review. The meta-analsysis found QOL reporting/analysis techniques were heterogeneous. Nine RCTs reported the rate of completedbaseline assessment and compliance survivors at analysis of greaterthan 50%, for data synthesis.[1] Of these, only one trial found a significant difference in QOL between the comparator arms: paclitaxelplus cisplatin was better than teniposide plus cisplatin. However, teniposide is not used in practice today. Based on this review, it seems unlikely that a major difference exists in the global QOL associated with standard chemotherapy regimens for advanced NSCLC.[1] Furthermore, the authors concluded that although the available QOL reporting formats are largely acceptable, a lack of uniformity in analysis and a poor compliance to QOL assessment made between-trial comparisons difficult.[1]

A large single RCT of 926 patients (not included in the Tanvetyanon meta-analysis[1]) comparing docetaxel and cisplatin (DC) or carboplatin (DCb) with cisplatin /vinorelbine (VC) also examined QOL using the Lung Cancer Symptom Scale (LCSS) and the general EuroQol five-dimensional questionnaire (EQ-5D).[2] DCband DC were superior to VC in the QoL outcomes assessed except for the difference between DC and VC in LCSS ‘‘QOL today’’, which was not significant.[2]

There does not appear to be any major difference evident in the global quality of life associated with standard chemotherapy regimens for advanced NSCLC.[1]

Evidence summary and recommendations

Practice point

As overall quality of life does not seem to differ across the different chemotherapy regimens, the choice of chemotherapy in an individual patient may involve discussion regarding expected toxicities and the patient’s preferences.
Last reviewed September 2017